Value-Based Decision-Making at the Bedside

By Don Sharpe

Value in cancer care continues to present insightful and lively discussion among cancer care stakeholders. As the cost of cancer care escalates, physicians, payers, and patients are struggling with ways to contain costs and access treatments, without sacrificing quality of care. At the recently held National Comprehensive Cancer Network (NCCN) meeting in Hollywood, Florida, value in cancer care was the topic in a roundtable discussion. And, who better to discuss value in cancer care than an expert panel of physicians, policy makers, and a patient advocacy representative?

To tackle the topic of value, the panel first described their goals and use of NCCN Guidelines. Dr. Mohler immediately jumped in by saying that as an NCCN member institution, his organization is pledged to follow NCCN Guidelines, and the Guidelines are an integral part of the patient visit, “to the point where physicians often carry a print out into the room with them.” Dr. Mohler believes in educating and empowering the patient, and letting them decide on treatment choices as much as possible.

Dr. Edge agrees that NCCN Guidelines are widely used, but that it is important to remember that many patients fall outside of a Guidelines’ recommendation for various reasons. He estimates that Guideline concordance is about 80%, based on a study at Roswell Park. Dr. Bach was quick to point out that some aspects of Guidelines may not be perfect (e.g., CT scans in lung cancer or Avastin in breast cancer), and that one shouldn’t assume that following Guidelines immediately equates to quality care.

As a practicing oncologist and Medical Director at Anthem, Dr. Malin pointed out that there are 64 different regimens available in the NCCN Guidelines for non-small cell lung cancer patients with metastatic disease and no mutation. Nobody can handle that much information, thus the need for pathways, which narrow down those 64 regimens to a subset of regimens that in most situations will be the most “effective” for that patient. Effective can be interpreted as having the best efficacy, the best side effect profile, and if all else is equal, will be the most cost effective. Dr. Malin added that pathways are not created for payers, they are created for practicing clinicians, and pathways help bring value to the bedside through shared decision-making.

When asked, “Does Anthem look at pathways as a way of saving resources?” Dr. Malin responded, yes, to the extent that different regimens cost different amounts, and if on average the chosen regimen is lower cost, then there will be cost savings. But importantly, “if you look at the melanoma pathways at Anthem you will see that all the new drugs, like ipilimumab, are in there. Because there are ranges in cost of therapy, if we move toward value-based care we will see that the cost of care doesn’t rise as rapidly as it does without value-based care.”

Dr. Bach echoed that there are large variations in cost of therapies, probably caused by market problems. Although pathways feel like a form of sophisticated formulary management, much like tiered treatments as preferable or not, they are a logical response to these variations in cost of therapy. “To the extent that regimens are truly interchangeable, it makes sense to incentivize doctors to use the cheaper of two interchangeable regimens,” he said.

Ms. House pointed out that patients are behaving as consumers today, and according to a recent study, that as much as 60% of cancer patients are aware of Guidelines. “Unfortunately, people have more information when purchasing a car or TV than they do when choosing cancer treatment. And, needless to say, the treatment choice is an important one.” In the study Ms. House cited, over 50% of patients said they do not have enough information to make a treatment decision, yet they are the ones that have to live with that decision.

Dr. Edge moved the conversation to the realities of being a doctor. His practice is under pressure to produce more patients, and more revenue with less time and resources than he had at a comprehensive cancer center. According to Dr. Edge, the lack of information at the patient level, as pointed out by Ms. House, is a crisis. At the same time, according to Ms. House, patients can make a reasonable decision when they are given information.

As the discussion turned to economics, Dr. Malin became the focal point again, and in particular attention centered on the new Anthem incentive program of rewarding physicians $350 per month per patient for pathway compliance. Dr. Malin noted that cost problems were an issue because of the buy and bill system, and the revenue to the practice being driven by the margin on drugs. In the case of non-small cell lung cancer, regimens can range from $450 for 4 cycles of carboplatin/taxol to $65,000 for 4 cycles of 3 other drugs. “The difference in revenue to the practice for administering these regimens is enormous,” she said.

Dr. Malin explained that the goal of the $350 incentive is to keep the practice whole on average and make them less dependent on the drug margin from expensive therapies. Anthem is building accountability into their programs and will provide reports back to physicians on items like ER visits and hospitalizations, “but Anthem can’t manufacture money. If they pay doctors more in one way, I have to have savings in another way to offset it, otherwise insurance premiums go up.”

To what extent does cost impact physician choice? Dr. Mohler thinks physicians are largely ignorant of cost, and Americans are fascinated with what is new. Dr. Edge feels that cost can’t be ignored, but went on to explain that there are so many insurance products that despite their best efforts it is close to impossible to provide accurate cost information to patients. Linda House reinforced that as a result of financial toxicity patients are walking away from therapy, which again impacts quality care.

Other thoughts on cost highlighted by the panel included:

Recently approved cancer drugs cost up to $15,000 per month, yet patients who need these drugs can’t afford the high out-of-pocket co-pay costs

The average cost of premiums and out-of-pocket expenses is estimated to be $22,000 annually, yet the median family income (2009-2013) is roughly $50,000

Variations in co-pay costs depend on type of insurance plan; under the Affordable Care Act out-of-pocket cost is capped at about $6,000, but for many people even $6,000 can be unaffordable

Medical waste such as scans and diagnostics contribute to the high cost of care

Today, it costs about $1.1 million to die of advanced prostate cancer, whereas before the approval of 5 new drugs the cost was about $30,000

And so the cancer care debate on value marches on. Between the Q&A and the panel discussion, many in the audience felt that our healthcare system is in near crisis level, if not already at crisis level. And Dr. Mohler noted, “we can’t sustain the system we have.”